1.8.2007 | Von:
James Stewart
Darlene Clark
Paul F. Clark

Policy Perspectives

Sending countries

The primary dilemma facing any proposal for regulation is how to balance the rights and the needs of the main actors involved - healthcare professionals, developed countries and developing countries.

Most observers of globalisation agree that freedom of movement to improve one's professional and personal circumstances is a basic human right. Denial of this right by source countries is not a tenable strategy for dealing with the problem of migration. However, unfair terms of trade and the legacy of colonialism have created market conditions in which a wholesale reliance on free markets will devastate healthcare provision in developing countries.

The types of policies that can best improve outcomes for sending countries should focus on meeting domestic needs and addressing the "push" factors that motivate healthcare workers to emigrate. There is an urgent need for countries to examine medical education curricula to ensure that training programmes focus on domestic, rather than foreign, healthcare problems [1]. Improving compensation, working conditions and professional opportunities for healthcare personnel in their home countries would almost certainly reduce the impetus to leave. Some countries are trying less expensive incentives, such as better housing, subsidised transport to work, and inexpensive car loans. While many of the poorest nations do not have sufficient resources to make these types of improvements, some developing countries are exploring the use of international development funds to improve the remuneration packages for healthcare professionals – an option that did not exist in the past [2]. A coalition of government and nurse association officials in the Caribbean has gone one step further, by developing a comprehensive Managed Migration Programme that attempts to ensure "the delivery of quality healthcare to the people in the Caribbean, in the midst of significant migration of skilled professional nursing staff." [3] Developed and signed by a significant number of Chief Nursing Officers (top government officials) and by the presidents of the nurses' associations of most countries in the Caribbean, the programme lays out a plan of action to mitigate the impact of migration on healthcare in the region. The programme focuses on several areas, including terms and conditions of work, recruitment, retention and training. A recent agreement among governments will enable nurses to move more freely across borders. One initiative that has been undertaken under the auspices of the program is a St. Kitts program that trains nurses for employment in the US, with the US providing reimbursements for training costs. Another innovative project allows Jamaican nurses to work two weeks per month in Miami while working the remainder of the month in Jamaica [4].

Source countries could also intervene in the healthcare labour market by raising the cost of recruiting RNs or MDs from a developing country, in the form of a tax or a tariff on such transactions, to recover some of the training costs [5]. Unfortunately, such a provision is problematic in a number of ways and, to date, no country has taken this step. However, there has been some support in the international assembly of the WHO for a fund that would train healthcare personnel in developing countries negatively affected by migration. The fund would be financed by developed countries as compensation for the investment in training lost by developing countries [6].

Another strategy that some developing countries have actually initiated involves "bonding" graduates of healthcare training programmes. Bonding requires graduates of nurse and physician training programmes to work in the country that funded the training for a period of time, in partial payment for their publicly-funded education. However, implementing and enforcing these types of provisions have proved difficult [7]. If a worker decides to migrate, thereby abrogating the reimbursement contract, a "departure" payment could reasonably be claimed by public authorities in the country of origin. The question of whether the individual or the future employer should pay these costs is another important policy question, and who pays these costs would depend on the relative bargaining power of the worker and the employer.

In the absence of established and effective policies, and in the face of a growing consensus that the current patterns of globalisation affecting healthcare workers do not serve the interests of developing countries, some observes have called for developing countries to disengage from the current system. As a case in point, Physicians for Human Rights (PHR) has recommended that African countries resist the efforts to liberalise trade in health services advocated by the World Trade Organization [8].

Receiving countries

Policies that can be implemented by receiving countries to solve their problems and to generate more equitable outcomes for all parties should focus primarily on reducing the strength of "pull" factors that artificially increase migration. Some countries have already taken voluntary steps of this kind [9]. As an example, ethical concerns raised about the impact of migration on developing countries have caused the national health services in the UK and Ireland to adopt ethical guidelines for the recruitment of overseas nurses. These guidelines require the services to provide accurate and truthful information to potential recruits about terms and conditions of employment and, in the case of the UK, they prohibit the NHS from actively recruiting nurses from South Africa and the West Indies. However, these guidelines do not apply to private healthcare facilities. Nor do they restrict public healthcare systems from hiring foreign nurses who migrate and apply for positions on their own initiative. For this reason, their impact has been limited [10].

Another approach to regulating the migration of healthcare professionals is the signing of inter-country agreements that place limits on the number of professionals who can be recruited, thus minimizing the damage to the sending country's health system. In 2000, the UK signed such an agreement with Spain to engage in "the systematic and structured recruitment" of Spanish nurses for the NHS [11]. The United Kingdom has also discussed similar agreements with India and China.

In 2003, the NHS and the South African government reached agreement on an exchange programme entitling healthcare professionals of both countries to work in the other country for up to six months. Although the programme will probably bring more South African RNs and MDs to the UK than the reverse, the migration will be for a fixed period of time [12]. The Caribbean Community (CARICOM) has implemented a programme "to encourage [healthcare] professionals to work overseas on a rotational basis, going for three years or so and then returning." [13] The CARICOM nations hope this programme will encourage temporary, rather than permanent, migration.

Perhaps the most ambitious attempt to address the problems caused by the recruitment of healthcare professionals is the 2003 Commonwealth Code of Practice for International Recruitment of Health Workers. The code establishes an ethical framework to discourage the recruitment of such workers from countries experiencing shortages, and safeguards the rights of healthcare employees who choose to migrate [14]. The critical question is whether such bilateral or regional agreements can be effective in the context of global trade protocols emerging from the World Trade Organization.

However, the most direct way of reducing the power of pull factors in developed countries is for those nations to address the reasons underlying the shortages of healthcare professionals they encounter more aggressively. Ultimately, recruiting RNs and MDs from abroad is a stopgap strategy. These countries need to take steps to train and retain the personnel they need from among their own populations. Falling medical school enrolments are a major factor contributing to the shortage of physicians in the US, and a second contributing factor is soaring malpractice insurance rates.


The various policy initiatives discussed here constitute useful first steps toward addressing the problems associated with the increased migration of healthcare workers induced by the global crisis in national healthcare systems.

However, a long-term solution will require more active involvement from another group of actors – international and regional organizations such as the WHO, the ILO and PHR. These organizations have played an important role in examining and documenting the seriousness of migration and have also developed guidelines and codes of conduct that encourage the parties involved in migration to engage in responsible and ethical practices [15]. However, while these entities have the expertise to help source and destination countries alike, at present they do not appear to have the standing needed to impose the types of regulations on the labour market for healthcare professionals that are needed to address the complex and dynamic aspects of the problem. One possible strategy to improve this standing of regional and international organizations would be the development of formal agreements between regional and national governmental and quasi-governmental bodies which provided an international supervisory body with some degree of specific regulatory and oversight authority.


See PHR (2004).
See Brown (2003).
See RNB (2004): 1.
See Salmon et. al. (2007).
See Jordan, B. (2001): "Nurses face emigration tax." Sunday Times-Johannesburg. 9 Sep.
See Dugger, C. (2004): "Africa needs a million more health care workers, report says." The New York Times. 26 Nov., A27.
See Buchan, Parkin and Sochalski (2003).
See PHR (2004).
See Schmid (2004).
See Buchan, Parkin and Sochalski (2003).
Buchan and Dovlo (2004).
Mulholland, H. (2003): "UK agrees health staff swap with South Africa." The Guardian. 24 Oct.
Stilwell et al. (2004): 598.
Commonwealth Secretariat (2003).
See, for example, ICN (2001).



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